Version 5.1 Transactions (some transactions may be required at a future date to be determined):

NCPDPLowerVersionTransactionCode

NCPDP Lower Version Transaction Name

NCPDP V.5.1TransactionCode

NCPDP V.5.1 Transaction Name

Transaction Support Requirements

00

Eligibility Verification

E1

Eligibility Verification

Required

01 - 04

Rx Billing

B1

Billing

Required

11

Rx Reversal

B2

Reversal

Required

21 - 24

Rx Downtime Billing

N/A

N/A

Not supported in v.5.1.

31 - 34

Rx Re-billing

B3

Rebill

Required

41

Prior Authorization Request with Request for Payment

P1

Prior Authorization Request and Billing

Required

45

Prior Authorization Inquiry

P3

Prior Authorization Inquiry

Required

46

Prior Authorization Reversal

P2

Prior Authorization Reversal

Required

51

Prior Authorization Request Only

P4

Prior Authorization Request Only

Required

81 - 84

Rx DUR

N1

Information Reporting

No planned requirements at this time;

91 - 94

Rx Refill

N/A

N/A

Not supported in v.5.1.

N/A

N/A

N2

Information Reporting Reversal

No planned requirements at this time;

N/A

N/A

N3

Information Reporting Rebill

No planned requirements at this time;

N/A

N/A

C1

Controlled Substance Reporting

No planned requirements at this time;

N/A

N/A

C2

Controlled Substance Reporting Reversal

No planned requirements at this time;

N/A

N/A

C3

Controlled Substance Reporting Rebill

No planned requirements at this time;

Version 5.1 Transaction Segments Mandatory/ Situational/ Not Sent:

NCPDP : Request Segment Matrix

Segment Support Requirements

Segment\Transaction Code

E1

B1

B2

B3

P1

P2

P3

P4

Some segments may be required at a future date to be determined.

Header

M

M

M

M

M

M

M

M

Required

Patient

S

S

S

S

S

S

S

S

Required

Insurance

M

M

S

M

M

S

M

M

Required

Claim

N

M

M

M

M

M

M

M

Required

Pharmacy Provider

S

S

N

S

S

S

S

S

No planned requirements at this time; may be required at a future date.

Prescriber

N

M

N

M

S

S

S

S

Required

COB/Other Payments

N

S

N

S

S

N

S

S

Required

Worker's Comp

N

S

N

S

S

S

S

S

Not required.

DUR/PPS

N

S

S

S

S

S

S

S

Required

Pricing

N

M

S

M

M

S

S

S

Required

Coupon

N

S

N

S

S

S

S

S

No planned requirements at this time; may be required at a future date.

Compound

N

S

N

S

S

S

S

S

Required

PA

N

S

N

S

M

S

M

M

Required

Clinical

N

S

N

S

S

N

N

S

Required

Notes:
NCPDP Designations: M = Mandatory; S = Situational; N = Not Sent.
Some segments indicated as "Situational" by NCPDP, may be "Required" to support specific transactions for this program.

Important program highlights for v. 5.1:

The software/certification ID will control whether 5.1 claims will be accepted by the production system. Your software vendor will receive a number upon certification with Magellan Health. This number must be included on the transaction header segment.

On 12/16/2004 on-line compounds will be processed using the Compound Segment.

In cases where a repeating field is Required or Required When, the maximum number of iterations has been indicated.

Field requirement legend:

Code

Description

M

Designated as Mandatory in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1. These fields must be sent if the segment is required for the transaction.

S

Designated as situational in accordance with the NCPDP Telecommunication Implementation Guide Version 5.1. It is necessary to send these fields in noted situations. Some fields designated as situational by NCPDP may be required for all New York State EPIC transactions.

X***R***

The "R***" indicates that the field is repeating. One of the other designators, 'M', or 'S' will precede it.

Notes:
1. Specific field values that are required for the program are identified as "NYS EPIC Values Supported".
2. There may be additional information regarding field values in the Provider Manual.

Request segment and field requirements:

Transaction Header Segment - Segment Mandatory for all transactions.

Field

Field Name

Mandatory

NYS EPIC Values Supported

101-A1

BIN NUMBER

M

012345

102-A2

VERSION/RELEASE NUMBER

M

51

103-A3

TRANSACTION CODE

M

B1, B2, B3

104-A4

PROCESSOR CONTROL NUMBER

M

P024012345

109-A9

TRANSACTION COUNT

M

B1 = 1-4 B2 = 1-4 B3 = 1-4

202-B2

SERVICE PROVIDER ID QUALIFIER

M

01 = NPI, 07 = NCPDP (NABP) Provider ID

201-B1

SERVICE PROVIDER ID

M

NPI or NCPDP (NABP) Provider Number <provider specific>

401-D1

DATE OF SERVICE

M

Format = CCYYMMDD

110-AK

SOFTWARE VENDOR/CERTIFICATION ID

M

Assigned when software vendor is certified with Magellan Health; will reject if missing or not valid.

Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)) and the Prescription/Service Reference Number (402-D2) changed from the "P" (Partial Fill).
Required when the "P" (Partial Fill) is not the original fill and the Prescription/Service Reference Number (402-D2) has not changed.

457-EP

ASSOCIATED PRESCRIPTION/SERVICE DATE

S

Required when the "completion" transaction in a partial fill (Dispensing Status (343-HD) = "C" (Completed)).
Required when Associated Prescription/Service Reference Number (456-EN) is used.
Required when the "P" (Partial Fill) transaction is not the original fill.

458-SE

PROCEDURE MODIFIER CODE COUNT

S

Situational.

459-ER

PROCEDURE MODIFIER CODE

S***R***

Situational, Repeating.

442-E7

QUANTITY DISPENSED

M

Required for this program; expressed in metric decimal units.

403-D3

FILL NUMBER

M

Required for this program.

405-D5

DAYS SUPPLY

M

Required for this program.

406-D6

COMPOUND CODE

M

Required for this program.
0= Not specified
1 = Not a compound
2 = Compound

408-D8

DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE

S

Required for this program.

414-DE

DATE PRESCRIPTION WRITTEN

M

Required for this program.

415-DF

NUMBER OF REFILLS AUTHORIZED

S

Required for this program.

419-DJ

PRESCRIPTION ORIGIN CODE

S

Situational.

420-DK

SUBMISSION CLARIFICATION CODE

S

Required when needed to provide additional information for coverage purposes.
'2 - Other Override' required to override select Plan Limitation Exceeded for Maximum Quantity / Day Supply edits as of 11/01/04,
'7 - Medically Necessary' required for OCC 3 claims certifying the prescriber was consulted for this prescription,
'99 - Other' required for OCC 3 claims certifying an attempt was made to contact the prescriber

460-ET

QUANTITY PRESCRIBED

S

Situational.

308-C8

OTHER COVERAGE CODE

S

Required for this program for COB.
Value of 8 to be used for claims covered by primary insurer.
Value of 3 to be used for claims not covered by primary insurer
Value of 2 not allowed for adjudication <1/16/2006>
Value of 4 and 5 not allowed for adjudication <06/23/2008>
Value of 1 and 7 only allowed with override <11/18/2009>
Value of 6 not allowed for adjudication. <6/8/2010>

Required for this program.
01 = NPI
08 = State License Number
12 = DEA Number

411-DB

PRESCRIBER ID

M

Required for this program.
NPI, DEA Number, or NYS State License Number

467-1E

PRESCRIBER LOCATION CODE

S

Situational.

427-DR

PRESCRIBER LAST NAME

S

Situational.

498-PM

PRESCRIBER PHONE NUMBER

S

Situational.

468-2E

PRIMARY CARE PROVIDER ID QUALIFIER

S

Situational.

421-DL

PRIMARY CARE PROVIDER ID

S

Situational.

469-H5

PRIMARY CARE PROVIDER LOCATION CODE

S

Situational.

470-4E

PRIMARY CARE PROVIDER LAST NAME

S

Situational.

COB Segment - Segment not required for CoPay Only Billing (Value "8" in 308-C8) for transactions: B1 and B3. Segment is required for claims denied by primary carrier (308-C8 = 3,5,6,or 7). Where possible this segment is requested for all COB claims to allow for proper Manufacturer Rebate processing.